We’ve Wrapped Up 4 Medicare PET Coding and Coverage Resources for You!

CMS keeps a close eye on PET imaging, and that means you need to, too. Make sure you’re using all of these resources so you understand coding and coverage for this high-tech imaging option.

1. Know Where to Find NCD Details

Medicare has a National Coverage Determination (NCD) for PET scans, with specifics for everything from FDG PET for Breast Cancer to Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease. There are a variety of ways you can access the NCD. Here are just a few options:

  • Go to CMS’s Internet-Only Manuals page, and click 100-03 to access the NCD Manual. Click the link that includes sections 200-310.1. When the PDF opens, go to section 220.6, Positron Emission Tomography (PET) Scans.
  • Use the Medicare Coverage Database, and click the Indexes tab. Select National Coverage/National Coverage Determinations (NCDs)/NCDs Listed Alphabetically. When the Index opens, click P. On the P page, check both the PET and Positron Emission Tomography entries.
  • Search for PET coverage information in the NCD Lookup in your online coding solution. You may be able to search by NCD text, title, or section, depending on what your particular tool provides.

Do you really need to read the NCD? Yes! Section 220.6 covers more than 15 pages in the manual, and there are some coverage details that medical coders, providers, and patients should know.

2. Make the Most of MLN Matters

CMS recently released MLN Matters MM10319, “New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes,” effective Jan. 1, 2018. And that’s just one of the MLN Matters resources available for PET. For instance, MM6632 covers FDG PET for Solid Tumors, and MM3640 covers billing requirements for PET scans for dementia.

3. Keep Up With Claims Processing Instructions

The NCD Manual isn’t the only Medicare manual you need to check for PET info. Be sure to review the Medicare Claims Processing Manual, too. (It’s 100-04 on the same Internet-Only Manuals page listed above.)

Read chapter 13, section 60.19 for information on a local MAC’s ability to decide coverage in its jurisdiction for PET using radiopharmaceuticals for their FDA approved indications. This applies to oncologic imaging.

4. Look for Local Requirements

The general rule is that local MACs may make Local Coverage Determinations (LCDs) on the same topic as an NCD as long as the local policy doesn’t conflict with the NCD. And we just saw in section 3 that national Medicare lets local MACs make certain coverage decisions for oncologic PET. So be sure you’re complying with your local MAC’s rules, too.

Be on the lookout for LCDs and related articles, as well as fact sheets from your payer.

What About You?

How do you keep tabs on PET coverage and coding rules?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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